IOL options with impaired acuity after ERM peel

[chazas]

My eyes were both very myopic, around -9 each.  I’ve been happily wearing multifocal contact lenses for years.

Last April, I had a retinal detachment and an emergency vitrectomy – I got a scleral buckle and had a gas bubble. I almost immediately got a cataract.  I wanted to go with a multifocal IOL to correct the cataract, but then I developed a significant epiretinal membrane, which made hat inadvisable.  

A couple of weeks ago I had a combined second vitrectomy/membrane peel and monofocal IOL implantation.  They were aiming for -1 to -1.5 so that either I could decide to either use the eye for mini-monovision (get the other eye done plano later) or just have a consistent near/intermediate focus. Recovery from the membrane peel seems to be going ok – the surgeon says I’ve gone from 20/400 best corrected to about 20/80, though so far it’s not clear to me whether this eye will ever have sufficient acuity for easy reading.  The other problem is that we had a big refractive error – if I remember the numbers right, I’ve ended up about -4.5, but (at least with the stitch still in) wit about +2.25 of astigmatism.  The surgeon said that effectively leaves me around -3.5, an unhappy result.

She’s ruled out explantation of the IOL as too invasive because of the multiple surgeries, says that when things settle down I could do either a piggyback lens or have Lasik.

So here are the questions.

Has anyone had either a piggyback lens implant or Lasik to correct an IOL refractive error?  How did you choose the approach?

Any input on abandoning the mini-monovision plan and having both eyes done about the same, whether plano or about -1.5?  As a non-expert I would think that if I continue to have significant acuity problems with one eye, having both of them at about the refraction is probably going to give me better results.

As an alternative, has anyone ever heard of a strategy using one eye for everything and the lesser quality eye just for periphery/stereopsis?  I.e., not worry too much about where the “bad” eye ends up, and get a multifocal IOL (or just wear a multifocal contact) on the other.

Thanks for any thoughts.

[John C Hagan III, MD, FACS, FAAO]

THIS STRING IS TOO LONG PLEASE MAKE NEW POSTS ON NEW QUESTION

[chazas]

I haven't been here or to this thread for several years.  (Well, "thread", they've changed the format so much, odd.)  Anyway, the membrane in my right eye has continued to grow. I still have technical 20/20 vision, I have a lot of distortion and floaters in that eye but my brain seems to adjust the stereo picture from both eyes so my vision overall is fine.  My retina doc can't believe I can see through scar tissue that thick. However, he is finally recommending a peel in my right eye - he says if I couldn't get along with that eye only, it's probably time, and it's thick enough that if I ever want to do it, I should soon.  I will probably do it, but wondering if  anyone else has faced the decision of whether to peel or not when overall vision is still ok.

[chazas]

The ERM is slowly getting worse. I'm still 20/20 corrected in that eye, but I notice the symptoms - bent line distortion, lines that break up into hashes, and it's slightly darker/more opaque.  Combined with the huge floaters in that eye it's pretty annoying.  My retinal doc says wait and see, he'd be hardpressed to do a peel when I have technical 20/20, despite the problems.  I'm torn.  I've been through it in the other eye (albeit with a much worse membrane), and it was not pleasant but th eventual recovery was good.  Anyone else have to make this decision?

[JohnHaganMD]

No matter what you feel with 20/20 I doubt your surgeon will proceed with the surgery. Generally you want vision of 20/60 or worse

[chazas]

Thanks.  It's odd, 20/20 is not really reflective of the vision quality. It's hard to describe.

[JohnHaganMD]

You can have 20/20 but have distortion, (metamorphopsia), larger than normal (macropsia), smaller (micropsia), crowding of letters together, reduced color and glare  so 20/20 does not imply normal vision

[chazas]

Maybe I'm still not done with this nonsense.  Yesterday's 3 month retina checkup showed a small epireteinal membrane in my right eye.  So far no symptoms I can isolate - there's some haze around outdoor lights at night and inside under flourescents, but I also have a huge cloudy floater and some posterior capsule opacity, so I can't tell what's from what.  And I'm still 20/20 with glasses.  But once an ERM started in my other eye, it got very bad very fast.  Sigh.

[JohnHaganMD]

VSP is pretty specific in terms of what they will and will not pay for. Most VSP patients don't want to spend much or any money more that VSP allowable.  I also don't know how or if any optical would 'negotiate' a price. That might work in Europe or the Middle East but  bargain and barter are not a part of American retail.

[chazas]

In a high and opaque pricing situation with unknown profit margins, I never hesitate to ask if I'm being given the best price and/or for a discount. E.g., not for groceries, but for appliances.

[JohnHaganMD]

Thank you for the information. I have published a paper on the absolute high end of glasses which is called wavefront technology. Its very expensive and for most people is not worth the extra money.  This is a link to the paper:  http://www.omagdigital.com/article/Grinding_It_Out%3A_Wavefront_Spectacle_Lens_In_Clinical_Practice/805950/78197/article.html

JHagan MD

[chazas]

Thanks for the paper.  The anterior practice I go to sounds much like yours (integrated ophtmamologists/optometerists/opticians, with routine care pushed down to the lowest cost provider.  I understand the economics, but what it means for th e patient is if something is considered routine (i.e., you probably can't charge much for it) the patient really has to take responsibility for their own care.

So many of the buzzwords surrounding progressives seem to have little meaning other than as a marketing matter.  Everyone touts their lenses as "digital" and "free form" - but is anyone today really being fitted in anything else?  The cheap Zenni glasses are digital and free form.  And as I mentioned it is very hard as a consumer to tell what you're being given and how it differs from anything else on the market.  Opticians tout the service they provide as the differentiator, but that's very hard to quantify and clearly is not worth the price differential from the internet ultra-discounters, or even the  trendy moderate discounters like Warby Parker.